DEC 3-SED (1 of 2)

SUMMARY OF EVALUATION/ELIGIBILITY WORKSHEET-SERIOUS EMOTIONAL DISABILITY

Student: Student Name DOB: 00 / 00 / 2000

School: School Name Grade: Grade

Date / Instrument / Summary of Required Screenings and Evaluations
00 / 00 / 2000 / Hearing Screening: / Pass Fail dB (Intensity Level) Hz (Frequencies)
00 / 00 / 2000 / Vision Screening: / Pass Fail Far R 20/ L 20/
Near R 20/ L 20/
00 / 00 / 2000 / Two research-based interventions to address behavior/emotional skill deficiencies and documentation of the results of the interventions:
00 / 00 / 2000 / Summary of conference with parent(s) or documentation of attempts to conference:
00 / 00 / 2000 / Communication Evaluation:
00 / 00 / 2000 / Review of Existing Data:
00 / 00 / 2000 / Social/Developmental History:
00 / 00 / 2000 / Academic, Functional and Behavioral Observation across settings:
00 / 00 / 2000 / Educational Evaluation:
00 / 00 / 2000 / Psychological Evaluation (to include an intellectual evaluation):
00 / 00 / 2000 / Behavioral/Emotional Evaluation (which may include a behavioral/ emotional skill rating):
00 / 00 / 2000 / Other:


DEC 3-SED (2 of 2)

Student: Student Name DOB: 00 / 00 / 2000

School: School Name Grade: Grade

As a result of the required screenings, evaluations, and review of existing information, what do we now know about the student?

Strengths:
Needs:

Documentation of impairment in one the following areas:

A. An inability to make educational progress that cannot be explained by intellectual, sensory, or health factors.
B. An inability to build or maintain satisfactory interpersonal relationships with peers and teachers:
C. Inappropriate types of behaviors or feelings under normal circumstances:
D. A general pervasive mood of unhappiness or depression:
E. A tendency to develop physical symptoms or fears associated with personal or school problems:
F. A diagnosis of schizophrenia:

Documentation that the above condition(s) have been exhibited over a long period of time and to a marked degree:

What is the adverse effect on educational performance?

What evidence exists that the student requires specially designed instruction?

AFTER COMPLETING WORKSHEET, IEP TEAM MUST DETERMINE ELIGIBILITY.
(See Eligibility Determination Form)

Final 1-08